Reflux surgery, or fundoplication, is a definitive surgical treatment designed to correct structural defects in the lower esophageal sphincter (LES). In a healthy digestive system, the LES acts as a one-way valve that opens to allow food into the stomach and closes to keep acid inside. When this muscle weakens or relaxes inappropriately, acid and bile escape into the esophagus, causing persistent mucosal injury. Fundoplication structurally strengthens this junction by wrapping the gastric portion known as the fundus around the distal esophagus. The primary goal of treatment is long-term mechanical relief from acid exposure, prevention of esophageal scarring, and reduction in esophageal cancer risk associated with chronic mucosal inflammation.

1. Patient Preparation: General anesthesia is administered, and a urinary catheter and nasogastric tube may be placed.
2. Access and Insufflation: Small abdominal incisions are made to insert laparoscopic or robotic instruments along with a camera.
3. Mobilization: The surgeon dissects the tissues surrounding the esophageal hiatus and mobilizes the gastric fundus.
4. Hiatal Repair: If a hiatal hernia is present, the displaced stomach is returned to the abdomen and the diaphragmatic opening is tightened with sutures.
5. Fundoplication Wrap: The top portion of the stomach (fundus) is wrapped either completely (360 degrees) or partially (270 degrees) around the lower esophagus and secured with permanent sutures.
6. Verification and Closure: Surgical sites are inspected for bleeding, instruments are removed, and small skin incisions are closed with absorbable sutures or surgical glue.

• Durable Symptom Relief: Eliminates or significantly reduces chronic heartburn and acid regurgitation in up to 90% of patients long-term (SAGES 2021).
• Medication Independence: Allows most patients to discontinue daily proton pump inhibitors and antacid therapy.
• Healing of Mucosa: Reverses erosive esophagitis and stops ongoing mucosal injury caused by gastric acid and digestive enzymes.
• Hiatal Hernia Repair: Corrects anatomical displacement of the stomach during the same surgical session.
• Protection Against Complications: Prevents esophageal stricture formation and reduces the risk of aspiration pneumonia.

Initial recovery occurs within the first 1 to 2 weeks, during which physical activity is limited to light walking. Patients follow a strict liquid and puréed diet for 2 weeks, gradually progressing to soft solids over weeks 3 to 6. Swallowing difficulty is common initially due to tissue edema but resolves as swelling subsides. Full physical recovery and return to unrestricted solid foods typically occur within 6 to 8 weeks post-surgery.

Fundoplication is indicated for patients with documented gastroesophageal reflux disease who have not achieved adequate symptom control with medication. It treats chronic heartburn, acid regurgitation, reflux-induced asthma, chronic cough, laryngopharyngeal reflux, erosive esophagitis, and Barrett's esophagus. The procedure also repairs concurrent hiatal hernias, where part of the stomach slides into the chest cavity.

1. Undergo objective testing including esophageal manometry and 24-hour pH monitoring as recommended by ACG guidelines.
2. Complete upper endoscopy to evaluate esophageal mucosal inflammation and rule out malignancies.
3. Stop smoking at least 4 weeks prior to surgery to reduce pulmonary complications and promote tissue healing.
4. Discontinue blood-thinning medications and nonsteroidal anti-inflammatory drugs under the guidance of the care team.
5. Fast from solid food and liquids starting the midnight before the scheduled procedure.

1. Dysphagia (difficulty swallowing): Temporary in 10-20% of patients; persistent in 2-3% requiring endoscopic dilation.
2. Gas-Bloat Syndrome: Difficulty belching or vomiting, leading to abdominal distension and flatulence.
3. Wrap Slip or Failure: Recurrence of GERD symptoms or wrap herniation requiring revision surgery (5-10% over 10 years).
4. Organ Injury: Low risk of accidental perforation of the esophagus, stomach, or pleura (<1%).
5. Infection and Bleeding: Surgical site infection or internal bleeding occurs in less than 1-2% of cases.

Pre-Procedure Evaluation

Patients undergo objective diagnostic testing, including high-resolution esophageal manometry, 24-hour pH monitoring, and upper endoscopy. These tests confirm pathologic reflux and rule out motility disorders like achalasia.

Surgical Procedure

Under general anesthesia, the surgeon uses laparoscopic or robotic assistance to mobilize the stomach fundus and perform either a complete (360-degree Nissen) or partial (270-degree Toupet) wrap around the lower esophagus.

Immediate Post-Operative Phase

Patients are monitored overnight in a surgical recovery unit. Pain is managed, and a liquid diet is introduced once swallowing function is confirmed.

Dietary Progression and Recovery

Over four to six weeks, patients transition from a soft diet back to solid foods while the operative site heals and swelling decreases.

Long-Term Follow-Up

Follow-up visits occur at 2 weeks, 3 months, and 12 months to assess symptom relief, evaluate swallowing function, and adjust lifestyle modifications.